Provider Demographics
NPI:1902360548
Name:PORTER, MICHELLE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26308 TULIP TREE CT
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-6367
Mailing Address - Country:US
Mailing Address - Phone:413-313-1529
Mailing Address - Fax:
Practice Address - Street 1:1003 E FLORIDA AVE # 103
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4510
Practice Address - Country:US
Practice Address - Phone:951-652-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily